CODING AND PRACTICE MANAGEMENT CORNER

Frequently asked questions about coding for breast surgery

52 | by Linda Barney, MD, FACS; Mark Savarise, MD, FACS; and Eric Whitacre, MD, FACS

All of the image-guided oding for surgical services biopsy codes, 19081–19086, can be complicated due Why are there two separate specify that the biopsy is Cto the numerous rules, codes to report for breast inclusive of the placement guidelines, and exceptions— cancer operations with of breast localization all of which the Centers sentinel node biopsy and one unified code for mastectomy devices, including clips for Medicare & Medicaid Services frequently updates or lumpectomy with and metallic pellet when and revises. Consequently, the axillary node dissection? performed, and imaging American College of Surgeons The breast surgery Current of the biopsy specimen, (ACS) General Surgery Procedural Terminology (CPT) when performed. Coding and Reimbursement codes were developed when Committee (GSCRC) often axillary dissection was standard receives questions about therapy for breast cancer. coding, particularly for Modified radical mastectomy breast surgery. This column is coded 19307; lumpectomy responds to some frequently with axillary dissection is coded asked coding questions 19302. When sentinel lymph related to breast cancer node biopsy was developed, the operations, sentinel node code needed to be applied to both biopsy, ultrasound-guided core breast and melanoma procedures. biopsies, excision with wires, Code 38900 is an add-on code to intraoperative assessment be used with any lymph node of margins, and more. biopsy or lymphadenectomy code

V99 No 9 BULLETIN American College of Surgeons CODING AND PRACTICE MANAGEMENT CORNER

to indicate the intraoperative placement of breast localization describes the procedure where work done to identify the devices, including clips and margin status is indicated by any sentinel lymph nodes. Therefore, metallic pellet when performed, method and may include excision lumpectomy with sentinel and imaging of the biopsy of additional surrounding tissue node biopsy is billed using specimen, when performed. In for margins. As a corollary, codes 19301, 38525-51, and other words, you cannot report use code 19301 whether the 38900. Total mastectomy with separately for clip placement breast cancer is palpable or is sentinel node biopsy uses codes or specimen imaging, but that removed with preoperative 19303, 38525-51, and 38900. the code is appropriate for the placement of a localization wire. biopsy regardless of whether clip placement or specimen When a total mastectomy imaging are included. How do you code re-excision with sentinel node biopsy is of a lumpectomy cavity when performed, I obtain a frozen you must return for positive section of the nodes and Do you code differently margins on final pathology a proceed to dissect the axilla for excision with multiple week after a lumpectomy? if positive. Can I use multiple wires for localization Use code 19301-58 for codes for this procedure? than with one wire? lumpectomy with modifier | 53 This is a modified radical The new image-guided for “staged/related procedure mastectomy (19307) with sentinel localization codes are per in the postoperative period.” node mapping procedure lesion, not per wire. Multiple Indicate in the operative report (38900). The axillary node biopsy wires may be placed to identify that this procedure is a planned cannot be reported separately any lesion. An excision may return to the operating room from the axillary dissection. only be reported once through for a more extensive work. a single incision, regardless of the number of wires Can I code for injection of used for the localization. Could I code for the X ray radioactive tracer and blue dye of the operative specimen for sentinel lymph node biopsy? with CPT code 76098? If you preoperatively inject How do you code for For all image-guided breast radioactive tracer, report 38792. excision of additional tissue excisions, the radiographic Injection of blue dye, when for margins at the time of evaluation of the specimen is performed, is included in the lumpectomy? Is there a bundled into the localization sentinel node code, 38900. code for the added work of procedure, and should not orienting and inking margins? be coded separately. CPT codes 19120 and 19125 I perform ultrasound-guided are used for excision of breast core biopsies but do not leave lesions, where attention to How would I code for localization devices in the surgical margins and assurance intraoperative assessment of biopsy location. Should I use of complete tumor resection margins, for instance, with codes 19083 and 19084? is unnecessary. Oncologic radiofrequency spectroscopy? Yes. All of the image-guided resection with attention to There is no specific CPT code biopsy codes, 19081–19086, specify margins (lumpectomy or partial for reporting intraoperative that the biopsy is inclusive of the mastectomy), code 19301, assessment of margins by

SEPT 2014 BULLETIN American College of Surgeons CODING AND PRACTICE MANAGEMENT CORNER

For all image-guided breast excisions, the radiographic evaluation of the specimen is bundled into the localization procedure, and should not be coded separately.

any particular method, such fibroadenomas is 19105. The as preparing touch-prep or How do you code for FDA has also approved laser frozen specimens, which are intraoperative radiation or ablation of fibroadenomas, considered integral to the work placement of the different but a CPT code has yet to be 54 | of a lumpectomy for malignancy devices for brachytherapy? established. RFA and high- (CPT code 19301). Intraoperative At present, no code has been frequency microwave ablation guidance with ultrasound designated for intraoperative are considered investigational. imaging for assessment of radiation treatment of the If you have questions or margins can be reported (CPT breast. Codes for placement comments regarding this code 76998) only if permanent of brachytherapy catheters column, contact Sarah Kurusz, images are obtained and saved, are available and can be ACS Practice Affairs Associate, and an ultrasound report is used regardless of the brand at [email protected] or 202- entered into the medical record. (Mammosite, SAVI, Contura, 672-1505. If you have additional and so on). These codes are coding questions, contact the 19296 for delayed insertion and ACS Coding Hotline at 800-227- How should I code for nipple- 19297 for immediate insertion 7911 between 8:00 am and 5:00 sparing mastectomy and at the time of lumpectomy. pm, CST, excluding holidays.  skin-sparing mastectomy to distinguish them from total mastectomy? How do you code for Editor’s note All of these procedures are ablation of breast Accurate coding is the classified mastectomy for lesions with cryotherapy, responsibility of the provider. cancer and should all be microwave, RFA, or laser? This summary is only a resource coded with 19303. No special The Food and Drug to assist in the billing process. distinctions are made for the Administration (FDA) has not type of incision. The operative approved ablation of breast report should use the wording lesions with cryotherapy, “total nipple-sparing” or “total microwave, or radiofrequency skin-sparing” mastectomy ablation (RFA), or laser for to avoid confusion with a treatment of breast cancer. The subcutaneous mastectomy. CPT code for cryotherapy of

V99 No 9 BULLETIN American College of Surgeons